HF & anti-anginal adjuncts
also: sacubitril valsartan · ivabradine · nicorandil · hydralazine · ARNI
Overview
Second-line agents added when first-line heart-failure or angina therapy is insufficient — each with a distinctive mechanism.
Mechanism
Sacubitril/valsartan (ARNI) = neprilysin inhibitor (↑natriuretic peptides) + ARB → prognostic in HFrEF. Ivabradine blocks the sinoatrial "funny" (If) current → slows heart rate without affecting contractility (needs sinus rhythm, HR >75). Nicorandil is a K⁺-channel activator + nitrate-like vasodilator. Hydralazine (+ nitrate) is a direct arterial vasodilator (HF in Black patients / when ACEi-intolerant).
Indications
- Heart failure (after ACEi/BB/MRA): ARNI, ivabradine, hydralazine+nitrate
- Angina (after BB/CCB + nitrate): ivabradine, nicorandil, ranolazine
The agents
replaces ACEi/ARB
Need a 36-h washout from an ACE inhibitor (angioedema risk).
HFrEF / angina
Sinus rhythm only, HR >75; AE: luminous visual phenomena (phosphenes).
angina
AE: painful mouth/GI/anal ULCERATION; contraindicated with PDE-5 inhibitors (nitrate component).
ACEi-intolerant / Black patients; hydralazine can cause drug-induced lupus.
Adverse effects
Cautions & contraindications
Additive angioedema risk.
Works only in sinus rhythm.
Nitrate-like → severe hypotension.
Interactions
- Nicorandil + sildenafil (hypotension)
- ARNI + ACEi (angioedema)
Monitoring & kinetics
HF: U&E/K⁺, BP, symptoms; ivabradine: HR/rhythm
Oral. Second-line — added on top of the prognostic first-line drugs.
Source: NICE NG106 — Heart failure · BNF — Heart failure / nitrates